UCSF team: trauma screening should be standard in health care

Wanda Demus, 61, looks out of her apartment window before she gets ready to head to a medical appointment at UCSF in San Francisco, California, on Tuesday, May 5, 2015.

Wanda Demus, 61, looks out of her apartment window before she gets...

Experience with trauma is so pervasive in the United States and has such profound effects on a person’s physical and mental health that screening and treatment for anything from childhood abuse to domestic violence should be a standard part of mainstream primary care, according to a UCSF-led team of researchers.

In a paper published Wednesday, the team proposes a move toward “trauma-informed” primary care, in which health care providers develop an understanding of the effects of trauma on their patients and find ways to help patients feel safe and comfortable talking about their experiences and seeking help.

Just as doctors may ask their patients whether they smoke, drink alcohol or exercise — all of which can affect overall health — they also should be talking about past or ongoing trauma, said Dr. Leigh Kimberg, an author of the paper who worked as a primary care physician in the Maxine Hall Health Center, a San Francisco public health clinic, for 20 years.

“Trauma is a lot more common than people think. (Physicians) adopting trauma-informed practices can increase safety, reliability, trust, empathy — just create a more healing environment for everyone,” said Kimberg, a UCSF professor. The UCSF team worked with the Positive Women’s Network-USA, an Oakland advocacy group made up of women with HIV, to craft the trauma care proposal.

Photo: Liz Hafalia / The Chronicle

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Wanda Demus, 61, heads from home to a medical appointment at UCSF Parnassus in San Francisco, California, on Tuesday, May 5, 2015.

Wanda Demus, 61, heads from home to a medical appointment at UCSF Parnassus in San Francisco, California, on Tuesday, May 5, 2015.

Photo: Liz Hafalia / The Chronicle

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Wanda Demus (left), 61, and her partner Charles Burns (right) walk on 2nd Street as they head to UCSF Parnassus for Wanda's medical appointment in San Francisco, California, on Tuesday, May 5, 2015. They support each other through recovery. less

Wanda Demus (left), 61, and her partner Charles Burns (right) walk on 2nd Street as they head to UCSF Parnassus for Wanda's medical appointment in San Francisco, California, on Tuesday, May 5, 2015. They ... more

Photo: Liz Hafalia / The Chronicle

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Wanda Demus, 61, gets settled at home after returning from a recovery program last Friday in San Francisco, California, on Tuesday, May 5, 2015.

Wanda Demus, 61, gets settled at home after returning from a recovery program last Friday in San Francisco, California, on Tuesday, May 5, 2015.

Photo: Liz Hafalia / The Chronicle

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Wanda Demus, 61, gets ready at home before heading to a medical appointment at UCSF Parnassus in San Francisco, California, on Tuesday, May 5, 2015.

Wanda Demus, 61, gets ready at home before heading to a medical appointment at UCSF Parnassus in San Francisco, California, on Tuesday, May 5, 2015.

Photo: Liz Hafalia / The Chronicle

UCSF team: trauma screening should be standard in health care

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Serious health effects

Doctors increasingly are recognizing the serious, wide-ranging effects of severe trauma on a person’s health. They’ve long known that post-traumatic stress disorder — which for decades was assigned mostly to veterans returning from war — can lead to mental health problems and substance abuse issues.

But it’s only in the past 15 or 20 years that public health experts have come to accept that other forms of trauma can have similar effects. Plus, exposure to violence and other adverse events can negatively affect not just mental health, but physical health, too.

In particular, the Adverse Childhood Experiences Study — a long-term project involving 17,000 Kaiser Permanente members who were surveyed about their exposure to violence and family dysfunction — found strong correlations between trauma and a wide variety of health problems, including heart disease, diabetes and depression.

How trauma influences health isn’t always clear. It can have biological effects, from chronic stress that may cause inflammation, for example. And it can also lead to unhealthy coping mechanisms, such as excessive drinking, drug-taking or overeating.

Domestic violence trauma

Many health care providers began screening for domestic violence — which is thought to affect one in four women, according to the Institute of Medicine — a decade or more ago, in response to multiple studies that demonstrated negative health effects from living in ongoing violent, traumatic environments.

Photo: Liz Hafalia, The Chronicle

Wanda Demus, 61, gets settled at home after returning from a recovery program last Friday in San Francisco, California, on Tuesday, May 5, 2015.

Wanda Demus, 61, gets settled at home after returning from a...

The San Francisco Public Health Department began screening for domestic violence in all female patients in 1997. And Kaiser introduced similar screening for its members about 15 years ago.

But domestic violence is just one kind of trauma, which is a broad term that can include childhood abuse, rape, exposure to violence and other forms of crime, as well as many other kinds of difficult experiences. The UCSF group would like to see similar, and even more expansive, programs to address all of them.

The proposal released Wednesday is fairly simple, although putting it fully into practice will take time and resources, said Dr. Edward Machtinger, director of the Women’s HIV Program at UCSF and an author of the trauma paper. To begin with, the paper recommends primary care offices provide basic training about trauma to all staff — receptionists, nurses, physician assistants and doctors themselves.

Safe environment

That training can help build an office environment that is safe and warm for patients who may have trauma-related reservations about seeing a doctor. It starts with a receptionist who welcomes patients by name, addresses them with respect and speaks to them in a gentle and friendly voice.

In the examination room, instead of lecturing patients about recent weight gain or their inability to quit smoking, doctors might explain how some patients develop coping mechanisms to help them deal with bad experiences. Doctors then may ask their patients whether they have ever been hurt by a partner or suffered other abuse or violence.

If a patient feels comfortable enough to reveal experiences with trauma, and that leads to a dialogue, both the patient and the doctor can come to a better understanding and work together to improve the patient’s overall health, Machtinger said.

A clinic with a staff trained to recognize trauma and talk to patients about it can then build relationships with other agencies that offer programs to help people get therapy or access other helpful resources.

“Part of creating a trauma-informed environment is imagining the experience from the perspective of a patient, so many of whom are very frightened to come into a health care environment,” Machtinger said. “When we understand the connection between trauma and health, we get a better understanding of why our patients act and react the way they do.”

For example, he said, “When I have a patient who is struggling with substance addiction, I’ll often start the conversation by saying, 'Of course you’re smoking crack, tell me the different things that crack is helping you with. Is there anything we can do together to help you find ways to cope that might not be so harmful?’”

Machtinger is in the process of transforming his Parnassus Avenue clinic into a safe place for women to talk about and heal from current and past abuse. Many of his patients have endured a lifetime of trauma — from childhood abuse to ongoing domestic violence — and are now coping with substance abuse and mental health problems.

Trauma-filled life

Wanda Demus, 61, has lived with trauma almost her entire life. Her father physically abused her mother, and when Demus was just 15, she was left in the custody of a man who sexually exploited her — abusing her himself and forcing her into prostitution.

Demus turned to drugs and alcohol to cope and still battles addiction decades later; she got out of a rehabilitation facility just Friday. Every time she turns back to drugs and alcohol, her overall health plunges, Demus said. Just having a doctor to talk to about her history — who listens and doesn’t judge her — has helped.

“Eddy (Machtinger) helps me get into recovery, and his office, they’ll keep tabs on me, get me back on my meds,” Demus said. “I talk to Eddy about anything. I don’t lie to him. I don’t feel ashamed telling him about what’s really going on with me.”